Follow‑Up After Accidental Bupropion Overdose
Patients who accidentally ingest an overdose of bupropion require immediate emergency department evaluation, continuous cardiac and neurological monitoring for at least 24 hours (longer if sustained‑release formulation), and close observation for delayed seizures, arrhythmias, and cardiovascular collapse.
Immediate Emergency Department Management
All bupropion overdoses warrant emergency department presentation because seizures occur in approximately one‑third of overdose cases, and serious complications including cardiac arrest, arrhythmias, and death have been reported even with supportive care. 1, 2, 3
Seizures, sinus tachycardia, ECG conduction disturbances, hallucinations, loss of consciousness, and mental status changes are the most common serious manifestations requiring immediate intervention. 1
Contact a Certified Poison Control Center (1‑800‑222‑1222 or www.poison.org) for real‑time guidance, as there is no specific antidote for bupropion overdose. 1
Critical Monitoring Parameters and Duration
Sustained‑release formulations produce prolonged and delayed symptoms—patients may appear stable initially but deteriorate hours later as the drug continues to be absorbed from the wax‑matrix vehicle. 4, 1
Minimum observation period is 24 hours in a monitored setting (emergency department or intensive care unit) for any bupropion overdose, with extended monitoring required for sustained‑release (SR) or extended‑release (XL) formulations due to delayed peak plasma concentrations occurring 3 hours post‑ingestion and prolonged elimination half‑life of 21 hours. 4, 1, 5
Continuous cardiac telemetry is mandatory to detect QRS prolongation, conduction disturbances, sinus tachycardia, and arrhythmias that can progress to cardiac arrest. 1, 2, 5
Neurological monitoring for seizure activity must continue throughout the observation period, as seizures can occur early or be delayed and recurrent. 1, 4, 3, 5
Specific Clinical Interventions
Administer GABA‑A agonists (benzodiazepines) for seizure management or prophylaxis in moderate‑to‑severe overdoses, as these were used in the vast majority of cases requiring ICU admission. 5
Intubation and mechanical ventilation may be required in approximately one‑third of serious overdoses due to hypoxia from recurrent seizures, respiratory depression, or loss of consciousness. 2, 3, 5
Aggressive supportive care includes intravenous fluids, vasopressors for hypotension or cardiogenic shock, and treatment of hyperthermia, rhabdomyolysis, and metabolic acidosis when present. 1, 2, 3
Disposition and Resource Utilization
Most bupropion overdoses require ICU admission, with a median of 1.47 days per case spent in the emergency department or ICU, reflecting the high acuity and resource intensity of these patients. 5
Transfer to a tertiary care center with medical toxicology consultation is appropriate for moderate‑to‑severe overdoses, as specialized management improves outcomes in cases complicated by seizures, arrhythmias, or cardiovascular instability. 5
Total hospital length‑of‑stay averages 68.5 non‑psychiatric bed‑days per year at a single tertiary center, underscoring the prolonged monitoring and recovery period required. 5
Dose‑Dependent Risk Stratification
Overdoses exceeding 30 grams have been reported, with one case documenting a 28.2‑gram ingestion resulting in rapid progression to cardiogenic shock and fatal cardiac arrest despite aggressive resuscitation. 1, 2
Seizure risk is approximately 0.1% (1 in 1,000) at therapeutic doses of 300 mg/day, but rises dramatically in overdose, occurring in roughly one‑third of all overdose cases. 1, 3
Deaths have been reported in patients ingesting large doses, with multiple uncontrolled seizures, bradycardia, cardiac failure, and cardiac arrest preceding death. 1, 3
Post‑Discharge Follow‑Up
Psychiatric evaluation is mandatory before discharge for any intentional overdose, with close monitoring for suicidal ideation especially in patients younger than 24 years who carry an elevated risk with all antidepressants. 6
Medication reconciliation and safe storage counseling should address the narrow therapeutic window of bupropion and the serious consequences of accidental or intentional overdose. 5
Clearance of bupropion and active metabolites takes approximately 7–9 days, during which residual seizure risk may theoretically persist, though most acute symptoms resolve within 24–48 hours with supportive care. 7, 4
Common Pitfalls to Avoid
Do not discharge patients prematurely based on initial stability—sustained‑release formulations can cause delayed deterioration hours after ingestion. 4
Do not underestimate cardiovascular risk—bupropion overdose can cause rapid progression to cardiogenic shock, arrhythmias, and cardiac arrest even in young, previously healthy patients. 2, 3
Do not rely solely on symptom‑based observation—continuous cardiac and neurological monitoring is required regardless of initial presentation, as serious complications can emerge suddenly. 1, 5